Case Report: Ludwig's Angina - An Unusual Way of Treatment

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Case Report: Ludwig's Angina -- An Unusual Way of Treatment

From the First Department of Internal Medicine (MF, GR), ENT - Clinic (WB) and the Department of Radiology (ER), University of Vienna, Austria

Abstract: This case report describes a patient with Ludwig's Angina. The patient previously developed an allergic skin reaction to antibiotics. He then refused any further antibiotic treatment. As an alternative, he requested homeopathic treatment. Within 24 hours his septic fever decreased to normal, while the submandibular swelling transformed into a hemispherical infiltration at the angle of the mandible. From the infiltration a serosanguineous liquid oozed through a drainage hole without surgical intervention for about ten days. The swelling disappeared completely and the patient recovered without any sequelae.

Keywords: Ludwig's angina, septic fever, Lachesis muta, Echinacea, Myristica sebifera, Hepar sulphuris calcareum, Anthracinum

Introduction

Infection in the submandibular space (SMS) is exemplified by Ludwig's angina, a bilateral, brawny cellulitis spread by continuity not lymphatics, sparing glandular structures, and producing gangrene with putrid serosanguineous infiltration, with little or no pus, and no abscess formation.(1)

Although fungi and mycobacteria have been occasionally recovered, the bacteria that are normal components of oral flora are chiefly responsible for deep cervical infections. They become pathogenic when mucosal barriers are interrupted, such as during pharyngitis, and they can penetrate into the deeper spaces. These infections are due to a mixture of anaerobic and aerobic organisms, anaerobes predominating in a ratio of 3:1 to 6:1.(2,3)

When cultural confirmation of anaerobic infection is lacking, certain clinical clues may be helpful in suggesting the presence of anaerobes.3 A foul-smelling discharge is considered diagnostic but may be absent in half of confirmed cases. Gas production, tissue necrosis, and abscess formation are also suggestive. A rare reason for a submandibular space abscess is toxic shock syndrome.(4)

Most patients are young, healthy adults, with two or three times greater incidence in males.(5.6) The presenting symptoms are neck pain and swelling, tooth pain or recent extraction,(7) dysphagia.(6,8) Respiratory complaints of dyspnea, tachypnea, and stridor have been reported in as many as 27 percent of cases.(6) Other symptoms have included a muffled voice,(9) drooling(10) and tongue swelling (Juang).(8)

Submandibular space abscess is essentially a clinical diagnosis. Physical examination reveals a woody submandibular swelling,(6) mouth distortion secondary to enlargement of the tongue, which is elevated and often protruding.(5,6) Airway obstruction is a much feared and frequent complication of a submandibular space abscess. Respiratory compromise may result from obstruction by the swollen, displaced tongue, edema of the neck and glottis, extension of the edema to involve the epiglottis, and poor control of pharyngeal secretions.(2,6)

Usual treatment of all deep neck infections is hospitalization with airway management, IV antibiotics, and timely surgical exploration. This case reports of the homeopathic treatment in a patient who refused treatment with antibiotics.

Case Report

A 23 year-old male patient was admitted (day 1) to a peripheral hospital because of swelling of the sublingual and the left submandibular space. Temperature was 39.5øC. The patient received amoxicillin, oxacillin, diclofenac, and sucralfat. On day 2, a puncture of the left submandibular space was performed, but no pus could be found. Radiographic examination of the mandible showed only four impacted wisdom teeth, but no clear odontogenic source of the swelling. Sonography showed multiple cystic masses in the submandibular space confirming the clinical diagnosis of Ludwig's angina.

The fever remained high for the next two days and an allergic skin reaction to the antibiotics developed. The patient, who is of stubborn nature, required discharge from the hospital on day 3 despite intense elucidation by the doctors that he was suffering from a life-threatening disease with the potential danger of airway obstruction, descending necrotizing mediastinitis, aspiration pneumonia, lung abscess, etc.(11,l2)

When the patient was first seen by one of the authors (M.F.) on day 3 at 11:00 a.m., he presented with high fever of 39.7øC and massive woody submandibular swelling, predominantly on the left side. The face of the otherwise slim patient showed a swollen appearance with mouth distortion due to protrusion of the enlarged tongue. Swallowing was painful; the patient tolerated only soft nutrition. The patient refused any further antibiotic therapy and demanded homeopathic treatment. The clinical symptoms of septic fever (Kent: FEVER, Septic -- p. 1290), tension in the left (Kent: GENERALITIES: Sides, left -- p. 1401) submandibular region (Kent: FACE, Swelling, lower jaw -- p. 393), protruded (Kent: MOUTH, Protruded, tongue -- p. 415) and swollen (Kent: MOUTH, Swelling, tongue -- p. 421) tongue led to the decision to administer two globules of Lachesis muta CM (Schmidt-Nagel Pharmacy, Geneva, Switzerland). In addition, he received two globules of Echinacea 30c (Roethe Krebs Aptheke, Vienna, Austria) to support the patient's immune resistance during the septic condition (Boericke, Materia Medica, p. 263), and Myristica sebifera 200c (Roethe Krebs Aptheke, Vienna, Austria), a remedy of great antiseptic powers, the so-called "homeopathic knife," which hastens suppuration and shortens first duration, often more powerfully acting that Hepar or Silicea (Boericke, p. 452), respectively.

The patient noticed an increase in the swelling of the left submandibular space, fever decreased to 37.8øC at 11:00 p.m. of the same day. During the night, the patient suffered from profuse perspiration, while the submandibular swelling of the left side moved downwards and concentrated in an increasing swelling just below the middle of the left ramus of the mandible (Fig. 1).

Swelling of the tongue receded. In the morning of day 4 the body temperature was 37.0øC. The patient received another two globules of Myristica 200c and also two globules of Hepar sulphuris calcareum 30c to decrease the swelling and to support ripening of the infiltration. The clinical indication for Hepar was the tendency for suppuration (Boericke, p. 325). On day 5, the patient had no more difficulties with submandibular swelling, while the swelling at the left ramus of the mandible had reached a hemispherical shape with a diameter of about 5 cm and discharge of pus started (Fig.2). On day 6, he received two globules of Anthracinum 30(: which led to drainage of the swelling with discharge of putrid serosanguineous liquid without surgical intervention (Fig. 3). Anthracinum is known to be a great remedy in septic inflammation, carbuncles and especially in black and blue boils and blisters, as well as in gangrenous parotitis and foul secretions (Boericke, p. 54), as can be seen in this patient. Culture of this liquid showed no bacterial contamination. The discharge continued for about ten days after which the submandibular swelling disappeared entirely and a small scar remained.

The patient recovered completely and stayed in good health without recidivation during a two year observation period. Sonography six months after the acute disease showed a hypodense structure with a diameter of 1.3 cm in the left submandibular space relating to the fibrotic residue of an enlarged lymphatic gland without any other pathological findings.

Discussion

Usual conventional treatment of all deep neck infection is hospitalization with airway management, IV antibiotics, and timely surgical exploration. Up to half of all cases of Ludwig's angina are cured without surgical drainage procedures,(6,13) and up to 43 percent require tooth extraction.(8) There are also reports about complications following surgical drainage of a submandibular space abscess.(14)

This case report deals with the history of a patient suffering from Ludwig's angina. Due to an allergic skin reaction to the antibiotics administered, he requested homeopathic treatment. Within 24 hours septic fever decreased to normal while the submandibular swelling transformed into a hemispherical inflammation at the ramus of the mandible, from which a serosanguineous liquid oozed through a drainage hole without surgical intervention for about ten days. This report shows that in cases of Ludwig's angina homeopathic treatment serves as a valuable tool when antibiotics cannot be administered for various reasons.

Bibliography

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American Institute of Homeopathy.

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By Michael Frass; Gerhard Resch; Wolfgang Bigenzahn and Erich Steiner